1428 - A Case of Delayed Depth Perception Recovery after a Precentral Gyrus Stroke

Case Diagnosis: Medial rectus gaze palsy after precentral gyrus CVA

Case Description: 83 y/o female presented to outside hospital with slurred speech, left-sided facial droop, and diplopia. CTA revealed acute right precentral gyrus infarct. Patient was admitted to our acute inpatient rehabilitation (AIR) facility and reported severe diplopia. On exam, diplopia was found to be binocular; there was no diplopia when either eye was covered, strength 5/5 right, 4/5 left except 2/5 hand grip, mild left facial droop, right eye adduction limited to midline. Initial PT evaluation on AIR day 0 (AIRD0) found impaired depth perception. On AIRD1, patient reported improving diplopia; exam showed improved right eye adduction. By AIRD4, diplopia was fully resolved; exam showed full right eye adduction. However, depth perception impairments continued with PT, resulting in understepping while navigating stairs. Patient showed initial improvement on AIRD5, with gradual improvement through admission.

Discussions: Ocular dysmotility is frequently seen in strokes affecting the primary motor cortex, most commonly ptosis, mydriasis, and gaze palsy, resulting in diplopia. Höhler et al (2021) states eye movement disorders in stroke patients cause visuospatial impairments due to impaired input and integration of binocular information in the occipital cortex. Our patient’s right eye adduction impairment and diplopia were consistent with ocular dysmotility secondary to precentral gyrus infarct. Interestingly, impaired depth perception was likely caused by a different mechanism given continued deficits despite complete resolution of diplopia and medial rectus palsy.

Conclusions: Problems with visuospatial awareness may be associated with diplopia and gaze palsy, and functional impairments seen with impaired depth perception may persist even after improvement of extraocular findings. It is important for clinicians to understand ocular findings assessed at bedside may not accurately assess for visuospatial deficits. For this reason, patients with ocular impairments following stroke require comprehensive evaluation and an interdisciplinary approach.